Jet goes down on its way to Medellin, Colombia
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Map Shift?
The ADS-B data coupled with the nature of the actions taken in the final descent and the location of the crash site have brought out a puzzling issue. The ADS-B position while LMI2933 was holding at RNG VOR/DME are displaced about 10 nm south of the VOR itself. Either the ADS-B IRS position has drifted exceptionally, or is it possible the moving map shifted because of a bad navaid update?
The use of inertial data introduces drift. Normally, aircraft navigation systems account for drift by applying radio-nav updates to null out any accrued errors. I have no expertise with the RJ85 flight management or navigation system, so I can only guess what might have happened based on general experience (and happy to receive any suggestions or corrections).
When a moving map is provided, a navigation data base presents the fixed features, and the IRS provides the position and heading source.
IRS drift can be measured by comparing radio navigation aids to reveal any offset. Inherent in this calculation is the navigation data base that stores the location of the navaid.
The favored update is to take intersecting DME measurements from two VOR/DME. In the event only one navaid is available, a VOR/DME measurement may suffice.
A map shift is when the map moves suddenly to reflect a radio navaid update. Normally a map shift takes out the error, but in this case the question was it putting in an error.
If the DME or nav data base readings were in error on LMI2933, where LMI thought the navaid was in a different place displaced south by about 10 nm, then the flight crew might be confused and follow the map guidance without picking the error (by using DME 1 or DME 2 raw readouts, or looking at the VOR DBI when crossing over and turning outbound).
The flight crew had power when they started their emergency descent and were probably thinking they will make it.
The flight crew were diving for 10,000 feet by the final approach point (FAP), just 0.63 nm north of the VOR. They were setting up for capturing the 3 degree glide slope at the FAP.
If there was no map shift, and the moving map was correct, we have no answer for the decision to operate to the south.
LMI2933 powered rate of descent and configuration would be without regard to the issue of flameout.
If the flight crew knew where they were (assuming ADS-B reports are correct), then they still had 5,000 feet to the FAP in about 10 nm (or about 1,000 fpm).
If they thought they were operating north of where the ADS-B reports portray, because of a bad navaid map shift, then they might have thought they need to lose 5,000 feet to the FAP in just a couple of nm (or about 5,000 fpm).
The last report showed their rate of descent at around 2,500 fpm (prior to flameout). That suggests a map shift may have disrupted situational awareness and that they were thinking that they were much too high for the approach.
The extended glide slope would have been at about 13,000 feet 20 nm out, and 16,000 30 nm out. LMI2933 would have been above the glide slope before the engine flameout, yielding no useful information beforehand.
Note that DME is lost on EMERG AC/DC power, and if the crew looked at the VOR once power was lost (from the moving map), it would have shown the same radial in either case.
The ADS-B data itself is more consistent with a 2 nm error in reported position (noting that the ADS-B data source probably does not reflect radio navaid updates), which suggests a gross error in technical performance to the holding pattern. A map shift is one explanation. This is a quandary that will be cleared up with the official report.
The ADS-B data coupled with the nature of the actions taken in the final descent and the location of the crash site have brought out a puzzling issue. The ADS-B position while LMI2933 was holding at RNG VOR/DME are displaced about 10 nm south of the VOR itself. Either the ADS-B IRS position has drifted exceptionally, or is it possible the moving map shifted because of a bad navaid update?
The use of inertial data introduces drift. Normally, aircraft navigation systems account for drift by applying radio-nav updates to null out any accrued errors. I have no expertise with the RJ85 flight management or navigation system, so I can only guess what might have happened based on general experience (and happy to receive any suggestions or corrections).
When a moving map is provided, a navigation data base presents the fixed features, and the IRS provides the position and heading source.
IRS drift can be measured by comparing radio navigation aids to reveal any offset. Inherent in this calculation is the navigation data base that stores the location of the navaid.
The favored update is to take intersecting DME measurements from two VOR/DME. In the event only one navaid is available, a VOR/DME measurement may suffice.
A map shift is when the map moves suddenly to reflect a radio navaid update. Normally a map shift takes out the error, but in this case the question was it putting in an error.
If the DME or nav data base readings were in error on LMI2933, where LMI thought the navaid was in a different place displaced south by about 10 nm, then the flight crew might be confused and follow the map guidance without picking the error (by using DME 1 or DME 2 raw readouts, or looking at the VOR DBI when crossing over and turning outbound).
The flight crew had power when they started their emergency descent and were probably thinking they will make it.
The flight crew were diving for 10,000 feet by the final approach point (FAP), just 0.63 nm north of the VOR. They were setting up for capturing the 3 degree glide slope at the FAP.
If there was no map shift, and the moving map was correct, we have no answer for the decision to operate to the south.
LMI2933 powered rate of descent and configuration would be without regard to the issue of flameout.
If the flight crew knew where they were (assuming ADS-B reports are correct), then they still had 5,000 feet to the FAP in about 10 nm (or about 1,000 fpm).
If they thought they were operating north of where the ADS-B reports portray, because of a bad navaid map shift, then they might have thought they need to lose 5,000 feet to the FAP in just a couple of nm (or about 5,000 fpm).
The last report showed their rate of descent at around 2,500 fpm (prior to flameout). That suggests a map shift may have disrupted situational awareness and that they were thinking that they were much too high for the approach.
The extended glide slope would have been at about 13,000 feet 20 nm out, and 16,000 30 nm out. LMI2933 would have been above the glide slope before the engine flameout, yielding no useful information beforehand.
Note that DME is lost on EMERG AC/DC power, and if the crew looked at the VOR once power was lost (from the moving map), it would have shown the same radial in either case.
The ADS-B data itself is more consistent with a 2 nm error in reported position (noting that the ADS-B data source probably does not reflect radio navaid updates), which suggests a gross error in technical performance to the holding pattern. A map shift is one explanation. This is a quandary that will be cleared up with the official report.
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lemme, I only have access to a BAe146-300 speed card and the speeds might be a few knots off compared to an RJ85 for the same weight. That said, it would appear they were far too slow for a glide. Speed for glide is Vfto + 30. Vfto for a 146-300 at 33000 kg is 165 knots, so best glide would have been around about 195 knots. That is with gear down or up, the only thing that would change that speed is flap selection and they wouldn't have been able to do that (unless possibly they already had Flap 18 in the hold).
For the glide, once you get the gear down, if you are unable to select flap, then you increase speed to maintain the 1NM / 1000' gear down glide profile. In other words that 1/1 profile is an easily remembered target that is achievable with the gear down rather than the best the aircraft can do.
For the glide, once you get the gear down, if you are unable to select flap, then you increase speed to maintain the 1NM / 1000' gear down glide profile. In other words that 1/1 profile is an easily remembered target that is achievable with the gear down rather than the best the aircraft can do.
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Hi all. Just a bit of clarification on the above. I'm sat in La Paz watching the evening news as I type. The Minister of Public Works wrote to AASANA today requiring that TAM suspend commercial civilian flights for failing to meet ICAO operational safety requirements. This is what is also being currently reported online. However, while there were some cancellations earlier, TAM are very much still operating this evening. TV is showing both a copy of the letter to AASANA and live footage from one of the Santa Cruz airports.
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There is an article on Celia in the current "El Deber" which includes her statement giving her side of the story and explaining her presence in Brazil. She says she has been under pressure to alter her original report.
The statement shows as a jpg file and needs magnifying to make it legible. It confirms what is already know rather than add much that is new.
Castedo: "Me ordenaron modificar el informe" | Noticias de Bolivia y el Mundo - EL DEBER
Oh and the Government has grounded TAM, the military airline .....
The statement shows as a jpg file and needs magnifying to make it legible. It confirms what is already know rather than add much that is new.
Castedo: "Me ordenaron modificar el informe" | Noticias de Bolivia y el Mundo - EL DEBER
Oh and the Government has grounded TAM, the military airline .....
Yes, the investigation seems to be finally gearing up, as the Bolivian opposition parties have said it was far too slow, they've only just sealed LaMia's office and owner Rocha has done a bunk, but they appear to have tracked him down in Colombia.
Headlines from just one of the nationals:
-Lamia manager ex-General Vargas has been formally charged with Culpable Homicide and other charges, currently in jail on remand.
-His son has been arrested. DGAC offices raided. ( Guess they've been busy shredding since the 29th Nov! )
-DGAC and Asaana lawyers contesting who is responsible for authorising flights and one of the Att Generals has relayed his exasperation at not being able to establish this basic principle.
-Attorney General Brazil has begun to look at Lamia flight authorisations over Brazil and LaMia's links to football clubs.
-Some investigations started of "technical staff at Santa Cruz VV.
- TAM confusion , as posted upthread. ( Headless chickens, an FAA downgrade in mind?)
- Journalists starting to uncover the sub & contractor links between LaMia and Star - the go-between for the Lamia quotes to football clubs.
Re the 2 non-operational Lamia planes stored at the hangar:
After an inspection in the hangar of the Bolivian Air Force (FAB) in Cochabamba, a departmental committee of prosecutors ordered the sealing of the two aircraft company Lamia, for research purposes and possibly so they can be used in payment of compensation The anti-corruption prosecutor, Jaqueline Ponce explained that these aircraft are available to the Public Ministry. They are sequestered as they are related to a crime, are proceeds of crime and it will also serve to pay damages ," Ponce said.
Fiscalía secuestra los dos aviones de LaMia en Cochabamba | Los Tiempos
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More info on the TAM (non) suspension, again from Bolivian TV news this evening. There is a turf war on between the military and civilian authorities. TAM have said that only the head of the armed forces or Minister of Defence have the authority to suspend their civil passenger services. Ergo, we currently have the situation of a Bolivian operator still able to run scheduled commercial passenger flights, beyond the reach of the country's civil aviation authorities, despite government criticism for failing to meet ICAO safety standards. Hopefully this will cast some light for those not so familiar with Bolivia on the culture and industry background against which LaMía were able to operate.
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Wow, just wow. For once PPRuNe is spreading the news, rather than just writing it.
This thing is massive and has more layers than a French pastry.
Keep up the good work guys, great journalism and forum inputs coming from South America right now. (your Northern counterparts could learn a lot)
This thing is massive and has more layers than a French pastry.
Keep up the good work guys, great journalism and forum inputs coming from South America right now. (your Northern counterparts could learn a lot)
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About the descent from the hold speculation -
SKRG 290300Z VRB02KT 9999 -DZ BKN015 SCT080 17/16 A3025
Might they have been diving below that layer at 8000agl (FL150), knowing they had lost, or were soon to loose, nav instruments and hoping to get visual?
I'm not a fan of speculation, but I'll put that up there as a counter to all the ADSB drift cruft.
The investigation will answer the questions about what happened during that fateful flight. I'm more interested in keeping the conversation directed toward revealing the murky truth surrounding the preceding years that lead up to it.
SKRG 290300Z VRB02KT 9999 -DZ BKN015 SCT080 17/16 A3025
Might they have been diving below that layer at 8000agl (FL150), knowing they had lost, or were soon to loose, nav instruments and hoping to get visual?
I'm not a fan of speculation, but I'll put that up there as a counter to all the ADSB drift cruft.
The investigation will answer the questions about what happened during that fateful flight. I'm more interested in keeping the conversation directed toward revealing the murky truth surrounding the preceding years that lead up to it.
Last edited by Hippy; 9th Dec 2016 at 02:29. Reason: typos
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On paper, they had about US $16k [$16,000 United States Dollars]. Anyway if it's true, perhaps it helps add another explanation to this shared denial & risk-taking?
1) How much would it cost to refuel this aircraft, assuming virtually empty tanks, in that region?
2) Had LaMia been put on C.O.D. (Cash On Delivery) by its vendors and suppliers?
3) Did LaMia have any credit facilities or were they traveling with cash to pay for fuel?
4) What would be the landing fees and related costs to land in Medellin, and for a fuel stop in Bogota or some other airport?
Last edited by thcrozier; 9th Dec 2016 at 05:12.
It's analogous to an observer using ADS-B to monitor the height of an aircraft on approach, forgetting that it's displaying QNE whereas the crew will be seeing QNH-adjusted height on their altimeter.
ADS-B tells its own version of the truth.
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Over the years I observed pilots ignoring / not noticing / even not believing, very accurate 'raw data', favouring 'more comfortably feeling', but (due falsely corrected or not corrected drift, shift etc.) very inaccurate, sophisticated (situational enhancing, moving map type, etc.) data.
When I questioned this, the answer was: "Too much work and NOWADAYS errors are USUALLY negligible..."
'Attitude' / Airmanship ?
Never give up on your 'basics', no matter what you fly!
When I questioned this, the answer was: "Too much work and NOWADAYS errors are USUALLY negligible..."
'Attitude' / Airmanship ?
Never give up on your 'basics', no matter what you fly!
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Widow of FA David Vacaflores says...
Found one source linked to what I've been looking for:
One claim, that supports the allegation that Albacete (Venezuelan fugitive in Spain) may still own the LaMia planes, received income from the charters.
8th Dec . Wife of dead LaMia FA- David Vacaflores - reveals some of what she knows to a journalist and she says, wtte - although Albacete's version is that he isn't linked to LaMia Bolivia, she's saying he doesn't know meaning of truth, he needs to come and face the music, the suffering of the bereaved.
El turbio pasado de LaMia: la aerolínea a la que los futbolistas confiaban sus vidas - Univision
Also here's a basic diagram charting 8 flights CP2933 made between Aug – Nov 2016. (Nothing new, just based on FRadar24 data.)
Antes de estrellarse, el avión de LaMia forzó la reserva de combustible en otros ocho vuelos - Univision
One claim, that supports the allegation that Albacete (Venezuelan fugitive in Spain) may still own the LaMia planes, received income from the charters.
8th Dec . Wife of dead LaMia FA- David Vacaflores - reveals some of what she knows to a journalist and she says, wtte - although Albacete's version is that he isn't linked to LaMia Bolivia, she's saying he doesn't know meaning of truth, he needs to come and face the music, the suffering of the bereaved.
“The ownership structure of Lamia is a mystery. In an interview with the newspaper El Confidencial in Spain , Albacete said that was not part of the company, only he rented their planes in Bolivia. But Pamela Justiniano, widow of the head of the crashed aircraft cabin, David Vacaflores, told Univision that this version is false. "Mr. Ricardo is also a partner of the company, it will not be rented planes '' she said.
According to several sources consulted in Bolivia, Vargas negotiating with those who wanted to hire Lamia's services. Albacete received into bank account payment for these services.
At the insistence that in Spain the businessman said a different version, Justiniano shot back: "Truth what a shame with him, did not do shame of not being able to add value and come to face and know all the suffering that we are having now?"
The widow of the head of the ill-fated airplane cabin, Pamela Justiniano said that, in the regular operation of the company, Albacete received payment for the income of flights and then the money was distributed to employees.
"What I know, he also received the payments, he also deposited it to the accounts payments teams.
According to several sources consulted in Bolivia, Vargas negotiating with those who wanted to hire Lamia's services. Albacete received into bank account payment for these services.
At the insistence that in Spain the businessman said a different version, Justiniano shot back: "Truth what a shame with him, did not do shame of not being able to add value and come to face and know all the suffering that we are having now?"
The widow of the head of the ill-fated airplane cabin, Pamela Justiniano said that, in the regular operation of the company, Albacete received payment for the income of flights and then the money was distributed to employees.
"What I know, he also received the payments, he also deposited it to the accounts payments teams.
Also here's a basic diagram charting 8 flights CP2933 made between Aug – Nov 2016. (Nothing new, just based on FRadar24 data.)
Antes de estrellarse, el avión de LaMia forzó la reserva de combustible en otros ocho vuelos - Univision
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The fact that the ADS-B data being sent was subject to inertial drift doesn't necessarily imply that the crew didn't know exactly where they were. I haven't seen any suggestion that while they were flying the hold, prior to it all going quiet, they didn't have a working VOR/DME. (Well OK, the RNG DME could theoretically have been sending duff data, but Occam's Razor applies here).
It's analogous to an observer using ADS-B to monitor the height of an aircraft on approach, forgetting that it's displaying QNE whereas the crew will be seeing QNH-adjusted height on their altimeter.
ADS-B tells its own version of the truth.
It's analogous to an observer using ADS-B to monitor the height of an aircraft on approach, forgetting that it's displaying QNE whereas the crew will be seeing QNH-adjusted height on their altimeter.
ADS-B tells its own version of the truth.
I apologize for my wording. I assume the pilots were talking stock in the moving map as their source of position. My concern is whether the map may have shifted, putting the map position about 10nm north of the actual position. This would explain the decision to descend so rapidly and early landing configuration.
I think the ADS-B data is accurate to a couple of nm. I have looked at four flights on this airplane and can confirm its performance. It was disappointing that the IRS was not aligned at takeoff, with a 2000 meter offset evident.
Of course there is more information available to the investigation that should end any speculation. I have no other insight other than an apparent map shift to explain all the data we have released.
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Yes definitely not CVR, this is LiveATC remember...
You mention TWR frequency,(the recording does not indicate the frequency unless you have found it somewhere) but this controller is dealing with Approach Control procedures involving several aircraft including LaMia. Not normally handled by Tower controllers but can be at non-busy airports. ( But no radar control going on here as I have mentioned before which if true is a little odd. There are several radars covering the Medellin Terminal Area).
You mention TWR frequency,(the recording does not indicate the frequency unless you have found it somewhere) but this controller is dealing with Approach Control procedures involving several aircraft including LaMia. Not normally handled by Tower controllers but can be at non-busy airports. ( But no radar control going on here as I have mentioned before which if true is a little odd. There are several radars covering the Medellin Terminal Area).
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For those wondering about the Cockpit Voice Recorder stopping when the airplane reverted to EMERG AC/DC power. There is a mandate for a 10 minute Remote Independent Power Supply (RIPS) for the CVR that applies here in the US to newly manufactured airplanes starting in 2010. I doubt that CP2933 was modified voluntarily to add this feature.
The flight data recorder relies on a cascade of sensors that are not reliable under EMERG AC/DC power, along with the drain to power the acquisition unit and the data recorder. Keeping in mind that the battery is needed for the continued safe operation, data recording takes too much current.
FYI, there is an ICAO GADSS initiative that in 2021 mandates an autonomous tracking system that will operate on its own power, but the jury is out whether ELT or ADS-B will be used for compliance. I am hopeful ADS-B, but it will take work to make it self-sufficient.
The flight data recorder relies on a cascade of sensors that are not reliable under EMERG AC/DC power, along with the drain to power the acquisition unit and the data recorder. Keeping in mind that the battery is needed for the continued safe operation, data recording takes too much current.
FYI, there is an ICAO GADSS initiative that in 2021 mandates an autonomous tracking system that will operate on its own power, but the jury is out whether ELT or ADS-B will be used for compliance. I am hopeful ADS-B, but it will take work to make it self-sufficient.
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Update 5 - Impact and breakup sequence
@Evanelpus -
I caught your question when catching up on reading the posts. Do not have the link immediately available I am afraid.
I have seen 2 videos made when circling the southern and northern side of the crashsite.
The first video, available early on, was shown on a website which showed a tv show named "JG". On this low quality video the horizontal and vertical tail are shown white. Which made it look like a wing or piece of tail.
The second video was from a spanish/portuguese language website and dated I think from december 1st (I found it december 7th). This video clearly shows the horizontal and vertical tail and the colored lines livery. The leading edge of the vertical tail is pointing down. The horizontal tail is still connected.
One of the photos that I found earlier, viewpoint from below, clearly shows the tailspeedbrake folded. Part of the horizontal tail (left hand half) is clearly visible higher up and behind it.
What is striking is that there is as far as I know no trace of the cockpit section and forward fuselage section. My impression is that it is more probable that these can be found near the main wreckage. But it is not impossible that it could be found on the initial impact side. All POB have of course been accounted for. So people on location and the investigation will know.
What strikes me too is that both recorders have been found in the first days, but no mentioned has been made of their contents at all. You hope of course that they were both switched ON and operating. What you would have expected is a general statement that confirmed that the plane ran out of fuel.
Based on the publicly available information you also begin to wonder if the crew had issued a warning to crew and passengers at some stage. The available witness testimony appears to suggest that POB were very surprised when the lights went out. Hence their reaction. You almost get a 'cognitive dissonance at play' feeling of how the cockpit crew would have perceived possible low fuel warnings. You would need both CVR and FDR information to substantiate that. But if found true it will become one of the most exceptional examples of CD.
@Evanelpus -
Got a link?
I have seen 2 videos made when circling the southern and northern side of the crashsite.
The first video, available early on, was shown on a website which showed a tv show named "JG". On this low quality video the horizontal and vertical tail are shown white. Which made it look like a wing or piece of tail.
The second video was from a spanish/portuguese language website and dated I think from december 1st (I found it december 7th). This video clearly shows the horizontal and vertical tail and the colored lines livery. The leading edge of the vertical tail is pointing down. The horizontal tail is still connected.
One of the photos that I found earlier, viewpoint from below, clearly shows the tailspeedbrake folded. Part of the horizontal tail (left hand half) is clearly visible higher up and behind it.
What is striking is that there is as far as I know no trace of the cockpit section and forward fuselage section. My impression is that it is more probable that these can be found near the main wreckage. But it is not impossible that it could be found on the initial impact side. All POB have of course been accounted for. So people on location and the investigation will know.
What strikes me too is that both recorders have been found in the first days, but no mentioned has been made of their contents at all. You hope of course that they were both switched ON and operating. What you would have expected is a general statement that confirmed that the plane ran out of fuel.
Based on the publicly available information you also begin to wonder if the crew had issued a warning to crew and passengers at some stage. The available witness testimony appears to suggest that POB were very surprised when the lights went out. Hence their reaction. You almost get a 'cognitive dissonance at play' feeling of how the cockpit crew would have perceived possible low fuel warnings. You would need both CVR and FDR information to substantiate that. But if found true it will become one of the most exceptional examples of CD.
The Colombians have sent the FDR and CVR to the UK AAIB at Farnborough for analysis (which is probably where they still are). The AAIB will not under any circumstances announce their findings publicly as that would be a breach of the convention that the country responsible for the investigation under Annex 13 should be the sole source of published information.
How and when the Colombians do that remains to be seen.
It was only a matter of time
At least eight flights made by the aircraft Lamia Airline prior to the incident in which players Chapecoense crew died, violated aviation regulations relating to weight and jet fuel, as is apparent from a table of itineraries obtained by Univision Investiga and analyzed by experts.
At least eight flights made by the aircraft Lamia Airline prior to the incident in which players Chapecoense crew died, violated aviation regulations relating to weight and jet fuel, as is apparent from a table of itineraries obtained by Univision Investiga and analyzed by experts.
28 Oct. Cochabamba-Medellin. Traveling empty.
Obviously the revenue flights weren't, but that's another story.
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@DaveReidUK
Dave I am quite familiar with the protocol of a SAFETY investigation and agree with you 100% on the UK AAIB role. AAIB shall stay silent both from a safety and from a criminal investigation point of view. The fact that we have a UK manufacturer here makes that requirement even more strict.
So what I am talking about is the way in which this multinational mixed investigation is running.
What happens here is that the investigation till now is a confusing mix of criminal and safety investigation. We have seen in for example the Lubitz case that a (French) criminal prosecutor operates under different rules. And also that that investigation was neither a showcase for clear separation between criminal and safety investigation.
In the LaMia case a number of people have been arrested and interrogated before safety investigators have had any chance (as far as we know) to interview them. And others probably have a warrant out for them. Which can be seriously 'damaging the cause of safety' from a purely safety investigation point of view.
If this investigation would predominantly be a criminal investigation, then it is surprising that a number of government and public officials have their verdict out before presenting any facts. Innocent until proven quilty and such. Surprising even if we assume that in a number of cases part of their 'message' will be 'lost in translation'.
In both criminal and safety investigation cases there are means and protocols in place that allow investigators to initiate and publish 'early' recommendations and actions.
In this case there appear to be a number of issues ... the 4h22/4h22, and the fact that flight release authority is not clear, ... that might not need to have to wait for publication of 'suggestions' in tandem with the first preliminary 30 days report.
Still striking.
I don't see why that should come as a surprise - see my previous post on the protocol of accident investigation.
So what I am talking about is the way in which this multinational mixed investigation is running.
What happens here is that the investigation till now is a confusing mix of criminal and safety investigation. We have seen in for example the Lubitz case that a (French) criminal prosecutor operates under different rules. And also that that investigation was neither a showcase for clear separation between criminal and safety investigation.
In the LaMia case a number of people have been arrested and interrogated before safety investigators have had any chance (as far as we know) to interview them. And others probably have a warrant out for them. Which can be seriously 'damaging the cause of safety' from a purely safety investigation point of view.
If this investigation would predominantly be a criminal investigation, then it is surprising that a number of government and public officials have their verdict out before presenting any facts. Innocent until proven quilty and such. Surprising even if we assume that in a number of cases part of their 'message' will be 'lost in translation'.
In both criminal and safety investigation cases there are means and protocols in place that allow investigators to initiate and publish 'early' recommendations and actions.
In this case there appear to be a number of issues ... the 4h22/4h22, and the fact that flight release authority is not clear, ... that might not need to have to wait for publication of 'suggestions' in tandem with the first preliminary 30 days report.
Still striking.